WQ0000807_Application_20240726

State of North Carolina
D Department of Environmental Quality
Division of Water Resources
Division of Water Resources 15A NCAC 02T .0600 — SINGLE-FAMILY RESIDENCE
WASTEWATER IRRIGATION SYSTEM —CHANGE OF OWNERSHIP
FORM. SFRWWIS-CO 03-21
Pursuant to 15A NCAC 02T.0107(bl if the application does not include all required information and the necessary supporting
documentation, the application shall be returned. The application and attachments shall be prepared in accordance with 15A
NCAC 02T .0100, 15A NCAC 02T .0600, and Division Policies. For more information, visit the Water Quality Permitting
Section's Non -Discharge Branch website. The Applicant shall submit an electronic copy of the application and attachments
uploaded as single Portable Document Format (PDF) file to httns://edocs.deu.ne.Lov/Forms/NonDisc harae-Bra neh-SuhnlitinI-_
Form -Vert, or emai led to Non -Di sch arQe.Renortsna nedenr.Fov if less than 20 megabytes (MB).
SECTION I — APPLICANT INFORMATION
1. Applicant: Sarah Thompson
2. Permit No.: WQ0000807
3. Signature authority: Sarah Thompson Title: Owner
4. Mailing address: 821 Bobbit Rd.
City: Mocksville State: NC Zip: 27028-
5. Contact person: Sarah Thompson Email:U M_akeheaith.edu
*�thompson8175@gm aii.com
Primary phone number: [phone] Cell Secondary phone number. [phone] Off -ice
6. Secondary Contact person: Email:
Primary phone number: ( } - Select Secondary phone number; ( ) - Select
SECTION U —FACILITY I212l(t ATION
1. Physical address: 821 Bobbit Rd. County: Davie
City: Mocksville State: NC Zip: 27028- JI
SECTION III —BILLING INFORMATION
1. Billing address: 821 Bobbit Rd.
City: Mocksville State: NC Zip: 27028-
SECTION IV —DEED INFORMATION
Hasa deed been executed and recorded in the County Rcgistcr of Deeds pursuant to 15A NCAC 02T .060410t 11?
® Yes — Complete Items 1 through 4 below.
❑ No — See Attachment B on Page 3.
1. Parcel No.; 5842854158 2. Date of Purchase: December20, 2023
3. Deed Book: 1266 1 4. Deed Page Nos.: 903 - 907
FORM: SFRW WIS-CO03-21 Page I of 3

SECTION V — OPERATION AND MAINTENANCE AGREEMENT
i Permit No.: WQ0000807
County: Davie
Pennittee: Sarah 'Thompson (i.e., all deeded property owners)
The Permittee agrees to operate and maintain the single-family residence wastewater treatment and irrigation system as
follows:
1. Inspect the septic tank annually, and pump out solids as needed.
2. Inspect and clean the septic tank effluent filter annually. (if applicable)
3. Inspect the tablet chlorinator weekly. Add wastewater grade chlorinetablets (a.g.,calcium hypochlorite)asneeded.
Swimming pool grade chlorine tablets are not acceptable. (if applicable)
4. Inspect the ultraviolet disinfection unit weekly. Clean or replace the lamps and quartz sleeves as needed. (if
applicable)
5. Inspect all storage tanks, pumps, and alarms monthly. Remove the floating scum layer in all pump/storage tanks
when pumping the septic tank solids out.
b. Inspect the spray irrigation system monthly to verify: proper operation of the spray heads; that there are no leaks;
that vegetative growth does not obstruct the spray heads; that the irrigated wastewater is not ponding in or running
off the designated irrigation area; and that there are no objectionable odors. (if applicable)
7. Inspect the drip irrigation system monthly to verify: proper operation of the drip Iines; that there are no leaks; that
vegetative growth does not obstruct the drip emitters; that the irrigated wastewater is not ponding in or running off
the designated irrigation area; and that there are no objectionable odors. (if applicable)
8. Maintain a set of Division -approved engineering plans and specifications.
9. Pay the required annual fee.
10. Request renewal of this permit on Division -approved forms no later than 180 days prior to expiration.
11. Sign and providea Change of Ownership application to any future owner of the single-family residence wastewater
treatment and irrigation system for their completion and submission to the Division of Water Resources.
I/We understand the ab ve requirements and agree to these terms as part of the issued permit.
Signature: Date: --72-to- ` 2-L4
Signature: Date:
Signature: Date:
Signature: Date:
All deeded prorwi-tv owners shall sign this Operation and Maintenance Agreement
FORM: SFRWWIS-0003-21 Page 2of3

ATTACHMENT A —SIGNATURE AUTHORITY DELEGATION
Does the signature authority in Section 1, Item 3 meet the requirements pursuant to 15A NCAC 02T .0I06(bi?
® Yes — Skip Attachment A.
❑ No — Submit a deleeation letter pursuant to 15A NCAC 02T .0I 06(c) authorizing the signature authority to sign.
ATTACHMENT B —PROPERTY OWNERSHIP DOCUMENTATION
Hasa deed been executed and recorded in the County Register of Deeds pursuant to I 5A NCAC 02T .0604(f)(1)?
® Yes — Complete Items 1 through 4 in Section IV on Page 1.
❑ No
❑ Submit a written notarized intent to purchase agreement sign by both parties with a plat or survey map pursuant to 15A NCAC
02T .0604(c)(2); or
❑ Submit a written notarized lease agreement that specifically indicates the intended use of the property and has been signed by
both parties, as well as a plator survey map pursuantto 15A NCAC 02T.0604(e)(3). Lease agreementsshali adhere to the
requirements of 15A NCAC 02L .0107.
APPLICANT'S CERTIFICATION
1, L�� ar SCE attest that this application
(Signature authority's name as noted in Section 1, Item 3)
has been reviewed by me and is accurate and complete to the best of my knowledge. I understand that if all required parts of this
application package are not completed, and that if all required supporting information and attachments are not included, this
application package will be returned as incomplete. I furthercertify pursuant to 15A NCAC 02T .0I 20(b), that the applicant, or any
parent, subsidiary, or othera ffiliate of the applicant has: notbeen convicted of environmental crimes under, not previously abandoned
a wastewatertmatment facility without properly closing the facility; not paid a civil penalty; not been compliant with any compliance
schedule in a permit, settlement agreement, or order; not paid an annual fee.
Note: The Applicant's Certification shall be signed pursuant to 15A NCAC 02T.0106(bl. An a ltemate person may be delegated as
the signing official if a letter is provided pursuant to 15A NCAC 02T .0106(c). Pursuant to § 143-215.6A and § 143-215.6B, any
person who knowingly makes any false statement, representation,orcertification in any application package shall be guilty of a Class
2 misdemeanor, wh' elude a fine not to exceed $10,000 as well as civil penalties up to $25,000 1perviolation.
Signature: Date:
THE COMPLETED APPLICATION AND ATTACHMENTS SHALL BE SUBMITTED AS A SINGLE PDF FILE VIA:
Email:
Non-Discha ree.Reno rts(ainedenr.eov_
Laserfiche Upload:
httDs:lledoes.deu.ne.aov/Forms/NonDischaree-Branch-
Subm itta I -Form -Vert
FORM: SFRW WIS-CO03-21 Page 3 of 3